Dear Doctor,

I am a heterosexual uncircumcised male.

I made a huge mistake and had unprotected vaginal (and I’m not sure but I think also briefly anal) sex with a prostitute from the red light area in Mumbai.  This happened multiple times throughout the night.

The very next morning she agreed to come for a Duo, RNA Qualitative, and VDRL test – all the results were negative.  I also took 2 grams Zithro, 800 mg Cefixime, and 2 grams Tinidazole as prophylaxis 48 hours post exposure.

My questions are as follows:

1.     Am I at risk for HIV and do I even need to test for HIV?

2.     Do I need to be concerned about her being in a potential window period considering she probably has sex every night with different customers, or did I truly dodge the bullet on this?

3.     I’m hoping the prophylaxis would prevent any bacterial STD - syphilis, chancroid, gonorrhea, chlamydia, trich, etc. – am I missing any STD’s that are endemic to India?  Do I need to do any STD testing for this exposure?

4.     Are Hepatitis B and/or C a risk from this and do I need to test?  If so, what would be the timeframe to wait before testing?

5.     Is it safe to immediately have unprotected sex with my partner without worry of HIV or any STD?

Thanks!

Welcome to the Forum.  While many of our clients overstate their risk for infection, I do have to agree with you that the events you describe were relatively high risk.  CSWs in Mumbai have a relatively high HIV rate although even there most CSWs do NOT have HIV.  Your partner's test results however indicate that there is almost no chance that she had HIV.  Presumably she has been a CSW for a while and has managed to not become infected by this time- it is unlikely that she did in the past 11 days which is the time not covered by the RNA PCR. thus your risk is quite low.  In answer to your specific questions:

1.     Am I at risk for HIV and do I even need to test for HIV?

I would not be worried about HIV in this circumstance.

2.     Do I need to be concerned about her being in a potential window period considering she probably has sex every night with different customers, or did I truly dodge the bullet on this?

One can never say never but, as explained above, the likelihood that she was infected and in the window is very low.  Further and equally important, if HIV was not detected in her blood by PCR, she was not infectious.  The situation is analogous to the situation in which persons with HIV do not transmit their infections when they are on effective HIV therapy and have no detectable virus in their blood.  No detectable virus = no risk for HIV transmission.

3.     I’m hoping the prophylaxis would prevent any bacterial STD - syphilis, chancroid, gonorrhea, chlamydia, trich, etc. – am I missing any STD’s that are endemic to India?  Do I need to do any STD testing for this exposure?

Although we would not recommend the sort of approach you took, the therapy you took should prevent any bacterial STIs. 

4.     Are Hepatitis B and/or C a risk from this and do I need to test?  If so, what would be the timeframe to wait before testing?

If you are vaccinated for hepatitis B, you are not at risk for that infection.  Hepatitis C is not meaningfully transmitted through heterosexual vaginal intercourse.

5.     Is it safe to immediately have unprotected sex with my partner without worry of HIV or any STD?

Were I you, I would not worry and would feel comfortable having sex with your regular partner

EWH

1.  Correct.  Undetectable means untransmittable. 

2.  Yes, this is a decision I would have made.

3.  Yes, that should be fine.

I hope this information is helpful.  EWH

If you had a negative RNA test at 11 days AND a negative DUO test at 6 weeks you can be entirely, completely confident that you did not acquired HIV. 

This is my 3rd response to your questions.  All of the information you have provided is very strong evidence that you were not exposed to HIV through the exposure you described and conclusive evidence that you did not acquire HIV.  I hope that you will be able to move forward from here.  As per forum guidelines, this thread will now be closed without further responses.  Take care.  EWH